LAKE COUNTRY ENDOSCOPY CENTER, LLC
NPI 1184897472
Clinic/Center - Ambulatory Surgical in Oconomowoc, WI

NPI Status: Active since April 08, 2008

Contact Information

1185 CORPORATE CENTER DR
SUITE 125
OCONOMOWOC, WI
ZIP 53066
Phone: (414) 454-0600
Fax: (414) 454-0971

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  • Organization
  • Clinic/Center
  • Ambulatory Surgical
  • Accepts Insurance
  • CLIA Number: 52D1090159
  • CLIA Cert. Type: Ambulatory Surgery Center
  • CLIA Exp. Date: 10-02-2026

About LAKE COUNTRY ENDOSCOPY CENTER, LLC

This page provides the complete NPI Profile along with additional information for Lake Country Endoscopy Center, Llc, a provider established in Oconomowoc, Wisconsin operating as a Clinic/center, focusing in ambulatory surgical . The healthcare provider is registered in the NPI registry with number 1184897472 assigned on April 2008. The practitioner's primary taxonomy code is 261QA1903X. The provider is registered as an organization and their NPI record was last updated one year ago. The authorized official of this NPI record is Bao Xiong Thao (Authorized Official)

NPI
1184897472
Provider Name
LAKE COUNTRY ENDOSCOPY CENTER, LLC
Entity Type
Organization
Location Address
1185 CORPORATE CENTER DR SUITE 125 OCONOMOWOC, WI 53066
Location Phone
(414) 454-0600
Location Fax
(414) 454-0971
Mailing Address
2801 W KINNICKINNIC RIVER PKWY STE 1080 MILWAUKEE, WI 53215
Mailing Phone
(414) 908-6615
Mailing Fax
(414) 454-0971
Is Sole Proprietor?
No
Is Organization Subpart?
No
Enumeration Date
04-08-2008
Last Update Date
01-08-2025
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Location Map

Specialty - Primary Taxonomy

The NPI enumerator requires providers to submit at least one taxonomy code. A taxonomy code is a unique 10-character code that describes the healthcare provider type, classification, and the area of specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.

Classification

Clinic/Center Ambulatory Surgical

Taxonomy Code
261QA1903X
Type
Ambulatory Health Care Facilities

Insurance Plans Accepted

According to publicly available information the provider might be accepting the following health plans from these health insurance companies:

  • Anthem Bronze Pathway/Lean 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives) - HMO
  • Anthem Bronze Pathway/Lean HSA (+ Incentives) - HMO
  • Anthem Bronze Pathway/Lean Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) - HMO
  • Anthem Bronze Preferred/Broad 5000 (3 Free PCP Visits + $0 Select Drugs + Incentives) - POS
  • Anthem Bronze Preferred/Broad HSA (+ Incentives) - POS
  • Anthem Bronze Preferred/Broad Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) - POS
  • Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) - HMO
  • Anthem Gold Pathway/Lean Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) - HMO
  • Anthem Gold Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) - POS
  • Anthem Gold Preferred/Broad Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) - POS
  • CareSource (Common Ground Healthcare) Bronze $0 Ded / $2500 Rx Ded - EPO
  • CareSource (Common Ground Healthcare) Bronze $0 Ded / $2500 Rx Ded - Vision Exam - EPO
  • CareSource (Common Ground Healthcare) Bronze $9600 ($45 PCP Copay) - EPO
  • CareSource (Common Ground Healthcare) Bronze $9600 ($45 PCP Copay) - Vision Exam - EPO
  • CareSource (Common Ground Healthcare) Bronze Standard $7500 - EPO
  • CareSource (Common Ground Healthcare) Bronze Standard $7500 - Vision Exam - EPO
  • CareSource (Common Ground Healthcare) Gold $0 Ded - EPO
  • CareSource (Common Ground Healthcare) Gold $0 Ded - Vision Exam - EPO
  • CareSource (Common Ground Healthcare) Gold $3300 - EPO
  • CareSource (Common Ground Healthcare) Gold $3300 - Vision Exam - EPO
  • Prestige Bronze $0 Medical Deductible - HMO
  • Prestige Bronze $0 Medical Deductible + Dental + Vision - HMO
  • Prestige Bronze $0 Medical Deductible + Dental +Vision - HMO
  • Prestige Bronze Essential + 3 Free PCP Visits - HMO
  • Prestige Bronze Essential + Dental + Vision + 3 Free PCP Visits - HMO
  • Prestige Bronze Plus - HMO
  • Prestige Gold - HMO
  • Prestige Gold 50 + 1 Free PCP Visit - HMO
  • Prestige Gold 50 + Dental + Vision + 1 Free PCP Visit - HMO
  • Prestige Gold 50 + Dental + Vision+ 1 Free PCP Visit - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE $0 MEDICAL DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE $10,150 DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE (DENTAL & VISION) $0 MEDICAL DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE (DENTAL & VISION) $10,150 DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE (DENTAL & VISION) STANDARD EASY PRICING - HMO
  • QUARTZ GUNDERSEN PERFORMANCE BRONZE STANDARD EASY PRICING - HMO
  • QUARTZ GUNDERSEN PERFORMANCE CATASTROPHIC $10,600 DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE GOLD $4,000 DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $4,000 DED - HMO
  • QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) STANDARD EASY PRICING - HMO
  • UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) - HMO
  • UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, Dental + Vision, No Referrals) - HMO
  • UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals) - HMO
  • UHC Bronze Standard (No Referrals) - HMO
  • UHC Gold Advantage ($0 Virtual Urgent Care, $5 Tier 2 Rx, No Referrals) - HMO
  • UHC Gold Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) - HMO
  • UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, No Referrals) - HMO
  • UHC Gold Standard (No Referrals) - HMO
  • UHC Silver Advantage ($0 Virtual Urgent Care, $5 Tier 2 Rx, No Referrals) - HMO
  • UHC Silver Advantage+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, Dental + Vision, No Referrals) - HMO

Specific plan information not avaialable, please contact the provider to verify if your insurance plan is accepted.

Specific plan information not avaialable, please contact the provider to verify if your insurance plan is accepted.

*Please verify directly with this provider to make sure your insurance plan is currently accepted.

Authorized Official

The authorized official is the designated individual with the legal authority to make changes to the provider’s official NPI record. For organizations, the authorized official must be a general partner, chairman of the board, CEO, CFO or a direct owner holding at least a 5 percent stake in the medical organization.

Authorized Official Name

BAO XIONG THAO

Authorized Official Title
AUTHORIZED OFFICIAL
Authorized Official Phone
(414) 908-6506

Additional Identifiers

The NPI Enumerator encourages providers to submit additional identifiers with their NPI application although the submission of this information is optional. The additional identifier(s) section includes other numbers or codes currently or formerly used as an identifier for the provider by other public healthcare entities. The identifiers may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Identifier Type / Code Identifier State Identifier Issuer
1184897472MEDICAID (05)WI 

Areas of Expertise

The following services and procedures, recently provided to Medicare patients, illustrate the range of care this provider offers. This list reflects the variety of services available to all patients visiting the practice and is based on 2022 Medicare dataset. In general, the more frequently a provider treats specific conditions or performs particular procedures, the more experienced they become in addressing similar patient needs. The provider has delivered many of the services listed below to Medicare patients. Please note that this list does not include services provided to patients who are not covered by Medicare.

Balloon dilation of esophagus, stomach, and/or upper small bowel using a flexible endoscope, less than 3.0 cm

This procedure involves using a flexible tube with a camera, called an endoscope, to gently expand narrowed areas in your esophagus, stomach, or upper small bowel. A small balloon is inflated, making it easier for food and liquid to pass through. It's safe and effective.

This service was performed 17 times for 17 patients

Biopsy of esophagus, stomach, and/or upper small bowel using a flexible endoscope

This procedure involves using a thin, flexible tube with a light and camera, known as an endoscope, to examine the esophagus, stomach, and upper part of the small intestine. Small tissue samples are taken for further examination to help diagnose various conditions.

This service was performed 132 times for 126 patients

Biopsy of large bowel using a flexible endoscope

A biopsy of the large bowel using a flexible endoscope is a procedure where a thin, flexible tube with a camera is inserted through the rectum to examine the bowel. If abnormal tissue is found, a small sample is taken for further examination. This helps in diagnosing conditions like inflammation, polyps, or cancer.

This service was performed 183 times for 182 patients

Colorectal cancer screening; colonoscopy on individual at high risk

Colorectal cancer screening, specifically a colonoscopy, is a preventive measure for those at high risk. A thin, flexible tube with a camera inspects the colon to spot any abnormal growths. This test helps detect potential issues early, enhancing the effectiveness of treatment.

This service was performed 102 times for 102 patients

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Colorectal cancer screening, such as a colonoscopy, is a preventive measure to detect early signs of cancer in the large intestine. For individuals not at high risk, it's typically recommended at age 50. A small, flexible tube with a camera is used to examine your colon. It's a safe, effective way to catch issues early.

This service was performed 42 times for 42 patients

Diagnostic exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope

This procedure, known as an upper endoscopy, involves inserting a thin, flexible tube with a camera down the throat to examine the esophagus, stomach, and upper small bowel. It helps diagnose conditions like ulcers or inflammation.

This service was performed 24 times for 24 patients

Diagnostic exam of large bowel using a flexible endoscope

This procedure, known as a colonoscopy, involves using a flexible tube with a light and camera to examine the large intestine. It helps detect any abnormalities such as polyps or inflammation. It's a standard procedure to ensure gut health.

This service was performed 11 times for 11 patients

Dilation of esophagus

Dilation of the esophagus is a procedure aimed to stretch or open up your esophagus (the tube connecting your mouth to your stomach) when it's narrow. It helps to improve swallowing and alleviate discomfort. It's typically performed using a flexible tube or balloon, under sedation.

This service was performed 23 times for 23 patients

Removal of polyps or growths of large bowel using an endoscope with mechanical snare

This procedure involves using a thin, flexible tube called an endoscope to examine the large bowel. If any abnormal growths or polyps are found, a tool called a mechanical snare is used to remove them. This is a common method to prevent potential health issues.

This service was performed 241 times for 239 patients

CLIA Information

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 applies to facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CLIA Program sets standards for clinical laboratory testing and issues certificates. The NPI / CLIA crosswalk information for this NPI number is:

CLIA Number
52D1090159
Facility Type
Ambulatory Surgery Center
Certificate Effective Date
October 03, 2024
Certificate Expiration Date
October 02, 2026
Laboratory Director
DR. JAMES T. KWIATT
Certificate Type
Certificate of Waiver
Certificate Type Description
This CLIA certificate is issued to Lake Country Endoscopy Center, Llc to perform only waived tests. CLIA defines waived tests as simple tests with a low risk for an incorrect result. Waived tests include certain tests listed in CLIA regulations, tests cleared by the FDA for home use and tests approved by the FDA for waived status and that meet CLIA waiver criteria.

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NPI NPI Number Validation

How NPI Validation Works

The NPI validation process uses the ISO-standard Luhn algorithm, a mathematical "handshake", to ensure that a provider's 10-digit ID is authentic and free of common typing errors.

To verify the NPI 1184897472, we treat the final digit (2) as the Check Digit—the target answer we need to reach. The process begins by taking the first nine digits and adding a constant value of 24, which accounts for the "80840" prefix required for all U.S. health identifiers. We then double every other digit starting from the right and sum the individual digits of those results together. For this specific NPI, that total comes to 68. The final step is to find the difference between that total and the next multiple of ten (70 - 68 = 2).

Digit-by-digit view

Use the first nine digits for the calculation. Starting from the right, double every other digit. The last digit is the check digit and is not part of the calculation.

Pos 1
1
Doubled → 2
Pos 2
1
Unchanged
Pos 3
8
Doubled → 16 → 1 + 6
Pos 4
4
Unchanged
Pos 5
8
Doubled → 16 → 1 + 6
Pos 6
9
Unchanged
Pos 7
7
Doubled → 14 → 1 + 4
Pos 8
4
Unchanged
Pos 9
7
Doubled → 14 → 1 + 4
Check
2
Target digit
Regular digit Doubled digit Check digit

Step 1: Double every other digit from the right

Starting with the rightmost digit of the first nine digits, double every other value. If doubling creates a two-digit number, add those digits together.

1 → 2 8 → 16 → 7 8 → 16 → 7 7 → 14 → 5 7 → 14 → 5

Step 2: Add all digits plus the NPI constant

Add the transformed values, the unchanged digits, and the constant 24.

2 + 1 + 1 + 6 + 4 + 1 + 6 + 9 + 1 + 4 + 4 + 1 + 4 + 24 = 68

Step 3: Find the amount needed to reach the next multiple of 10

The next multiple of ten after 68 is 70. The difference is the calculated check digit.

70 - 68 = 2
This NPI is valid
The calculated check digit is 2, which matches the last digit of 1184897472.

Other Providers at the Same Location


The following 20 providers are registered at the same or a nearby location.

Internal Medicine
1185 CORPORATE CENTER DR, PROHEALTH CARE MEDICAL ASSOCIATES INC.
OCONOMOWOC, WI 53066
Internal Medicine
1185 CORPORATE CENTER DR, PROHEALTH CARE MEDICAL ASSOCIATES, INC.
OCONOMOWOC, WI 53066
Surgery
1185 CORPORATE CENTER DR, SUITE 200
OCONOMOWOC, WI 53066
Family Medicine
1185 CORPORATE CENTER DR, PROHEALTH CARE MEDICAL ASSOCIATES
OCONOMOWOC, WI 53066
Internal Medicine
1185 CORPORATE CENTER DR, PROHEALTH CARE MEDICAL ASSOCIATES
OCONOMOWOC, WI 53066
Podiatrist (Foot & Ankle Surgery)
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Chiropractor
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Occupational Therapist
1185 CORPORATE CENTER DR, SUITE 155
OCONOMOWOC, WI 53066
Nurse Practitioner (Adult Health)
1185 CORPORATE CENTER DR, SUITE 300
OCONOMOWOC, WI 53066
Internal Medicine
1185 CORPORATE CENTER DR, SUITE 175
OCONOMOWOC, WI 53066
Nurse Practitioner
1185 CORPORATE CENTER DR, STE 175
OCONOMOWOC, WI 53066
Family Medicine
1185 CORPORATE CENTER DR, STE 175
OCONOMOWOC, WI 53066
Family Medicine
1185 CORPORATE CENTER DR, STE 175
OCONOMOWOC, WI 53066
Eyewear Supplier
1185 CORPORATE CENTER DR, SUITE 210
OCONOMOWOC, WI 53066
Internal Medicine (Cardiovascular Disease)
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Clinic/Center
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Nurse Practitioner (Family)
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Internal Medicine
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Clinic/Center (Primary Care)
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066
Nurse Practitioner (Family)
1185 CORPORATE CENTER DR
OCONOMOWOC, WI 53066

Frequently Asked Questions

The NPI number assigned to this healthcare provider is 1184897472, enumerated as an "organization" on April 08, 2008.

The provider is located at 1185 CORPORATE CENTER DR SUITE 125 OCONOMOWOC, WI 53066 and the phone number is (414) 454-0600.

Clinic/Center with taxonomy code 261QA1903X and a focus in Ambulatory Surgical.

The provider might be accepting Accepts: Anthem Blue Cross and Blue Shield, CareSource. Please consult your insurance carrier or call the provider to verify.